A cold, fine, misty rain was starting to envelop the Estonian capital Tallinn as autumn turned towards winter in the Baltic. Warm inside their conference centre, representatives of over fifty European states were facing up to the chills of potential cuts to national health budgets and how to deal with shifting winds of public demand, markets and political directions, as they reviewed five years of mixed progress since they agreed a Tallinn Charter in 2008 on strengthening health systems.

Many inspiring examples of improvements were cited from all corners of the diverse continent. Learned professors shared erudite insights into challenges and possibilities. Grand statements of intent were issued by ministers and well placed officials. All were valuable and welcome: under pressure from friends and foes alike to deliver, public health systems need all the help they can get in post 2008 Europe, as the Charter was devised in more conducive economic circumstances.

Key elements were deconstructed in animated discussions in breakout sessions: how to choose between innovative e-health, integrating care, or human resources? Part of a panel on public health, I argued for mainstreaming but realistic assessment: while some protective elements have been themselves protected from the worst cuts, so-called ‘’softer’’ aspects of health improvement, promotion and determinants approaches have been slashed almost to the bare bones in some places. A constructive session on tackling chronic or non-communicable diseases (when we have all sorted out the definitions it will be easier to work with others) is at risk of being undermined by the lack of capacity of public sectors to act on the growing evidence of cost effective interventions available, both within and beyond health systems.

Into that mix I rushed through a planned remark, about the need to consider trends towards consumerism in the context of evidence and effectiveness. I should have known better, for it was pounced upon by the remarkable Harvard Professor Marc Robert, a spellbinding earlier presenter and sage. I stumbled to clarify my views, reaching for the cloaks of humour and politics. The question deserved better. When the mist cleared, I knew I should have picked up the prompt. It is in fact a fundamental question at the heart of how public health systems will succeed or fail in the coming decade. It is also a metaphor for the future of the European Union, for it is about the interface where individual rights meet collective responsibilities, something which has been at stake ever since the EU took a role in public health and many other things beyond markets for widgets 20 years ago, something we will celebrate/commemorate at the major European public health conference in Brussels in November.

So let me raise just three points for now, which I think deserve deeper discussions in the context of health systems strengthening;

Markets are the dominant 21st century framework for societies, in Europe as globally. There is a clear market element with which public systems grapple in terms of products, services and safety, clearly a valid consumer-producer health dimension. But there are very different dynamics at play. Unlike many health system planners, I studied and practiced in business then politics before being involved in health policy. The mindsets are very different. Problem solving in commerce is rapid and focussed, competitive and often dictatorial; in public systems it is democratic, slow and complex by comparison. Yet the two approaches are being conflated. As a leading politician said recently: is it wise that health system decisions are increasingly made by competition lawyers rather than doctors? What is the public good?

If buzz phrases like health for consumers or patient centred health are meant to assuage me as an individual that I am not on a production line, I am not convinced. I am sometimes a patient, always a citizen, only a consumer when I must be because I believe in something bigger and more important: sustainable development. I don’t want health for growth or wealth. I want the wellbeing for all enshrined in the WHO founding Charter and the EU Treaty (its first article about objectives, not the specific health article, significantly). I see health as part of human development in tandem with social, knowledge, environmental and other aspects of societal progress. I think that is at the core of the Tallinn Charter, and many other WHO Charters as agreed in Ottawa or Alma Ata and many more since the WHO and EC began. So what are health systems for: just a basis for us to buy things or something more fundamental? If we know that answer, why do we keep talking why others sell us things?

I flew to Tallinn on a ‘’low cost’’ airline, not least to save public expenditure. I was treated shoddily, cramped, rushed to suit the company needs rather than my comfort. But that is similar to the model which I increasingly see advocated by powerful management consultants for solving the problem of apparent unsustainable health care in Europe. That itself is arguably a mirage, deliberately fostered because the solutions proposed by economic experts a decade ago of ‘’full engagement’’ in prevention and integrated care are demanding and put collective planning foremost. We heard in Tallinn how the German system has a surplus of billions of euros available for investment. Bad systems are unsustainable, real health and wellbeing is not. Better health is cheaper. But consumer demand is stoked in other directions than the evidence of effectiveness, often disingenuously. Independent bodies are undermined by media and vested interest groups whose background should be open to scrutiny. The whole basis of crucial scientific or cultural evidence is discredited. So effectiveness is side-lined in decision making in favour of consumer pressure. Individualisation is all, whether in communications or personalised medicines. Much of that can be good, much social innovation astoundingly helpful. But do we have the right frameworks so that the horse of whole system planning leads the cart of new mechanisms, concepts and ideas?

There are many other questions and issues in this dimension; I just scratch the surface for brevity. In Tallinn we heard enduring values re-affirmed: equity, accountability, universality, quality. There are wonderful, committed people involved. But are we being conned by some outside the conference warmth in the name of another colder value: affordability? There are fierce voices on all sides of that debate, but it is one we should not avoid before it is too late, as 20th century certainties dissolve in the winds of change sweeping Europe.

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